The article doesn’t start off too badly. It says that by 2025, there will be a shortage of 46,000 to 90,000 primary care docs. It then states that one of the reasons for the shortage is the relatively low pay that primary care docs get. This is true. Most primary care practices are consistently in the red due to low insurance payments, which is why there are very few independent practices anymore. Most are owned by hospital systems, who can absorb the loss.

That’s about where the sanity of this piece ends. According to it, the second reason for the shortage is that we have not “embraced technological advancements.” The article tells us that we need to deliver services via telemedicine and apps.

No matter that technology for this is still substandard.

No matter that there are serious concerns about cybersecurity and the safety of patient info.

No matter that using these technologies requires a substantial financial investments, of which no primary care doctor can afford.

No matter that there is absolutely no guarantee that insurers will actually pay for these services.
The article then goes on to give this sage advice:

And who the heck is going to staff these other locations? I thought they just said we’ve got a shortage of doctors! Maybe the staff of Medical Economics has discovered the secrets of cloning and can be in two places at once, but I haven’t figured it out yet.

It goes on to say:

Reevaluate office hours. Take a look at appointment patterns. Do most of your patients prefer appointments later in the day or earlier in the morning? Should you offer weekend hours? What about extending services later in the evening, when people are out of work? Instead of becoming complacent with standard office hours, test new hours and see how patients respond. Tailoring hours by office location will better serve patients while maximizing your staff’s time and resources.

See, here’s the thing. My schedule is full during standard office hours. Do I have patients that would love evening or weekend hours? Sure. But am I supposed to work 24 hours a day, 7 days a week? It’s not like I sit around twiddling my thumbs from the hours of 9-5. I’m seeing patients for just about every minute of that time, and doing paperwork during any time I’m not seeing patients (and after hours and on weekends, too). You can’t claim that there’s a shortage of doctors and too many patients to go around in one breath, and then claim that the doctors are the ones that need to be more accommodating in the next. Supply and demand, people.

Here’s the thing, Medical Economics. The reasons for the primary care shortage are many. Low pay. Low prestige. Too much paperwork. Every-increasing government and insurance regulations and requirements. And, most important of all, not enough residency spots for training doctors. There are only a certain amount of residency spots a year to train graduating MDs. If a doctor graduates from medical school but does not complete a residency, they can’t practice. They can’t get a license. Their education is, in essence, wasted. These are not bad students. There are just not enough spots. Every year, almost 10,000 doctors do not match! Most of these doctors have gone to international schools. All of them would do just about anything for the chance to practice medicine here.

It takes a 3 year residency to train a primary care doctor. If those 10,000 doctors a year were able to do an internal medicine, pediatrics, or family medicine residency, our shortage would be non-existent in less than a decade.

Medicare needs to fund more residency spots. Period. The way to solve a physician shortage is to make more physicians. It’s that simple, really.

The way to solve a physician shortage is not to place the responsiblity for it on the backs of those already bearing its brunt.

Well, I was never really gone…just on a little blogging hiatus as the new office gets up and running.

It appears than many of my new and prospective patients are Googling me, and many seem to have questions about who, exactly, I am. Therefore, I figured I’d make a little Frequently Asked Questions list.

Q: How old am I?
A: Old enough. Seriously, though, I think people are really asking one of two questions: “Is she some wet-behind-the-ears-fresh-out-of-school newbie?” or “Is she as old as the hills and 6 months away from retirement?” This answer is that I’m neither. I’m firmly in the middle-aged category. I graduated from medical school in 2000. I finished residency and chief residency in 2004, and I practiced in New Hampshire for 11 years before moving here.

Q: Where did I come from? Why did I move here?
A: I grew up in New Jersey. I lived in New Hampshire for 11 years before moving to Florida. I moved here to be closer to family and to get away from the endless snow and cold of New England.

Q: Why is my schedule so open?
A: People say this like it’s a bad thing! Don’t you want to be able to get into see your doctor? We just opened about 2 1/2 months ago. If you want to get in quickly to see me, now’s the time! However, even once I get really busy, I always leave openings in my schedule to see people the same day. If you can’t get in to see your doctor when you’re sick, what’s the point?

Q: Will I have to wait forever in the waiting room?
A: No. I like to run a tight ship and stay on schedule. Patients can help me do this by making sure they arrive for their appointment on time.

Q: Will I listen to you? Or will I rush you out of the room and just push prescriptions at you?
A: I will listen to you. I am definitely not one to push prescriptions. When they’re needed that’s fine, but I like to emphasize lifestyle changes and healthy living.

Q: What is “Marni” short for, anyway?
A: Nothing. That’s my full name.

Q: What happens if you get sick when the office is closed?
A: Call my office and you’ll get my answering service. I take my own calls, so they will patch you through to me, and we’ll talk about what to do.

Q: You have a doctor up north. Do you need to see me, also?
A: If you’re here for more than a couple of months, it’s a good idea to have a local primary care doctor. You never know when you might need someone, and it’s a good idea to have an existing relationship. I send copies of my office notes to your other primary care doctor.

Hopefully this answers your questions! If there’s anything I haven’t answered, feel free to write questions in the comments section!

I haven’t reviewed any exercise gear in a while, but I have a new toy to share!

There’s a lot of hype lately about “wearable technology,” especially with the upcoming release of the Apple Watch. Now, I’ll admit that the Apple Watch looks very cool, but it’s really out of my price range. However, I love gadgets, so I decided to spring for the new Fitbit Charge HR. For those of you not familiar with the Fitbit, it’s sort of like a pedometer…but so much more. Yes, it counts your steps. It also estimates your calorie burn, miles walked, flights of stairs climbed, and active minutes per day. All of the information syncs with your phone or computer. You can “friend” people for some friendly competition. I used to have a Fitbit One, which you clip onto your clothes, like a traditional pedometer. However, when I heard about the Fitbit Charge HR, I knew that I had to have it…because of it’s new feature, a heart rate monitor.

I’ve been working out with a heart rate monitor for years. It’s a great way to make sure that you are working out within your aerobic range, and I’ll do another post soon on training with a heart rate monitor. Traditional heart rate monitors are a chest strap that sends information wirelessly to a watch. I’ve used a Polar monitor in the past, and you wear the chest strap like this:

That’s not a picture of me. I wish.

The chest strap is very accurate at transmitting the heart rate. There are, however, some significant drawbacks. First, the contact points need to be moistened to work. Once you’re sweating, you’re pretty much good to go, but until then you need to wet the transmitter. Which basically involves licking your fingers and sticking them up your shirt. This is occasionally an awkward thing to do. Next, once you’re sweating, the band can slip down a lot (at least it did on me). This can become pretty irritating. Speaking of irritating, you can also develop quite a bit of chafing after a long run. I actually have scars just below my breastbone from chafing from my heart rate monitor.

The heart rate monitor on the Charge HR works differently. It’s an LED light that measures the blood flow in the capillaries below the skin (it works kind of like a pulse oximeter works at the doctor’s office). Therefore, you don’t need to have a direct skin contact point for it to work. The light is green, but I don’t find it to be noticeable unless I’m in a dark room and my wrist is flexed. Here’s what the lights look like- they’re on the underside of the watch.

And see? You can’t see them while you’re wearing it.

There’s a button on the side that you can press and the face will display the time, steps, calories, heart rate, and stairs climbed. You can also just tap on the face and get one of those displays to show up (mine shows heart rate).

I’ve been pretty impressed with the accuracy of the monitor. I tested it against my chest strap and it did pretty well. The only spots where it had trouble was if my heart rate was changing really rapidly (like I was running really fast and then stopped to walk) and in my spin class where it sometimes had trouble reading the rate because of how my wrist was flexed against the handlebars.

When you do a workout, you press and hold the button and it will start timing your workout. This will allow you to see what your heart rate does:

Fun! When you set up your account and put in your age, it’ll calculate out your heart rate zones. You can also manually set the zones.

If you wear it to sleep, it’s great for seeing how your resting heart rate decreases as you get more fit.

Speaking of wearing it to sleep, it’ll also tell you how well (or how badly) you’re sleeping at night. Bonus for its ability to set an alarm to wake you up with a buzz at your wrist.

The Fitbit app also integrates seamlessly with MyFitnessPal, which is a terrific calorie tracker. Using the two apps together is a really powerful tool to help lose or maintain weight.

The battery life is surprisingly long. I’ve gone 4 1/2 days without charging it, which is pretty impressive for something that is monitoring your heart rate 24 hours a day.

Overall, two thumbs up. I’ve been really impressed and I’m having a lot of fun with this little gadget!

Electronic medical records (EMRs) are pretty much the standard these days. What I’ve noticed is that that rather than providing a nice, succinct summary of a patient visit, they really just contain a lot of useless junk that is geared more towards data collection, ticking off boxes to satisfy billing requirements, and legal butt-covering.

Case in point:

I saw a patient recently who is on methotrexate. It’s a wonderful drug used for autoimmune conditions, such as rheumatoid arthritis. It works by inhibiting an enzyme that allows cells to metabolize folic acid, which is necessary for the growth of certain cells. Because of its mechanism of action, it’s completely contraindicated in pregnancy since it will stop the growth of a fetus. Obviously, you need to be careful when prescribing it to a woman who may become pregnant.

Anyway, back to my patient. I got a copy of the note from the specialist who prescribed the patient methotrexate. It includes a very comprehensive accounting of the extensive counseling of the risks and benefits of prescribing the drug, including the risk to pregnancy.

Looks good, right?

Only problem is…the patient in question is a 60 year old man.

I was sure to reiterate to him the importance of stopping the medication before he goes and tries to get pregnant.

On one hand, this is funny. But on the other, it’s really pretty pathetic. It’s a perfect example of how charts have become useless. It also tells me that even if the patient was counseled about methotrexate, this is not proper documentation, because there is no way he was told to his face to stop methotrexate 3 months before trying to become pregnant. That fact brings the veracity of the rest of the note into question.

But when you’re working off a template on an EMR, and you’re just pointing and clicking, it’s really easy to just cut and paste your boiler plate methotrexate summary into the chart.

I don’t have an EMR. And I like it that way. I dictate my notes. And I can guarantee that when you’re doing things the old-fashioned way, you would never document that you discussed the risks of pregnancy with a 60 year old man. Just because something is a bit more technologically advanced doesn’t mean it’s better.

You know how insurance companies drive me crazy with their drug approval forms? Well combine an insurance company with the government, and you get Medicaid. And when you get Medicaid, you get gems like this:

Approved? Unable to approve? Which is it???

On a side note…the best thing someone can do for their health is quit smoking. Forget about losing weight, exercising, getting a Pap smear. If you want to get the best bang for your buck, quit smoking. With this in mind, why is it that Medicaid will cover Buproprion and nicotine replacement like the patch or gum, but won’t cover Chantix? After all, the results for Chantix are superior to those for nicotine replacement. In the long term, it’s even cheaper than trying and failing other therapies. So, what gives, Medicaid? I don’t like requirements that my patients “try and fail” medications. I aim for success the first time out.